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BioMed Research International

Volume 2019, Article ID 7912371, 7 pages
https://doi.org/10.1155/2019/7912371

Research Article
Application of 3D Computed Tomography Reconstruction
Images to Assess the Thickness and Dimensions of the Posterior
Palatal Seal Area

Soeun Lim,1 Seoung-Jin Hong ,2 Joo-Young Ohe,3 and Janghyun Paek 4

1
Department of Prosthodontics, Kangwon National University Hospital, Chuncheon 24289, Republic of Korea
2
Department of Prosthodontics, Kyung Hee University Dental Hospital, Seoul 02447, Republic of Korea
3
Department of Oral and Maxillofacial Surgery, School of Dentistry, Kyung Hee University, Seoul 02447, Republic of Korea
4
Department of Prosthodontics, School of Dentistry, Kyung Hee University, Seoul 02447, Republic of Korea

Correspondence should be addressed to Janghyun Paek; [email protected]

Received 10 January 2019; Accepted 6 February 2019; Published 19 February 2019

Academic Editor: Heather F. Smith

Copyright © 2019 Soeun Lim et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Few studies have been reported on the scientific measurements of the thickness and dimensions of the posterior palatal seal (PPS)
area. The purpose of this study is to measure and analyze the thickness of palatal mucosa by using a three-dimensional (3D) model
reconstructed with computed tomography (CT) images and to present objective values by identifying the PPS area. The CT images
were reconstructed as a 3D model by separating the maxillary palate mucosa and teeth. Each reconstructed model was analyzed
and the thickness was measured at 93 crossing points of each divided plane. The dimension of the PPS area was measured and the
right and left dimensions of the PPS area were compared. The thickness of the palatal mucosa was thicker toward the posterior area.
The thickness increased in the lateral direction and decreased again. In the PPS area, the mean dimension between the rearmost of
anterior border and the most posterior line was 2.19 mm and the mean dimension between the forefront of anterior border and the
most posterior line was 5.19 mm in the right side and 5.16 mm in the left side. The mean dimension from the center of the palate to
the right most forward point was 6.85 mm, and the left was 7.36 mm. The new measurement method of palatal mucosal thickness
is noninvasive, accurate, and easy to store and study, so it can be used effectively in planning and manufacturing the maxillary
complete denture in the digital workflows.

1. Introduction film of saliva, and it affects the retention of the complete

denture. A tissue of the posterior palatal seal (PPS) area has
Complete denture treatment is a complex and challenging functional movement, and, during processing of the denture,
procedure that involves the design of the prosthesis. This a gap between the tissue and the intaglio surface of the
prosthesis is placed in the midst of a vital, dynamic oral denture is caused by the polymerization of the acrylic resin,
environment on a foundation that is very unstable. Therefore, mostly in the PPS area. Therefore, it is important to seal
clinicians must assure adequate retention, support, and stabil- hermetically in the PPS area for the retention of the maxillary
ity to achieve optimal results for complete denture treatments complete denture [5]. The PPS area can usually be extended
[1–3]. forward about 4mm from the distal border of the denture.
In routine clinical practice, border molding of the oral The seal may be a little wider than this in some areas, while
cavity is required to obtain maximum extension of the com- in the area where it passes through the hamular notch, it will
plete denture. For the preparation of the maxillary complete narrow to only 2 mm in width [6]. Silverman [7] performed
denture, the posterior border should be determined, and the a study on 92 patients to clinically, radiographically, and
sealing of the posterior area should be performed [4]. A histologically evaluate the PPS area and reported that the
change in ambient pressure causes the amount of air in the greatest mean anteroposterior width of the PPS area was
2 BioMed Research International

8.0mm (range 5-12mm). The mean width was found to be software, all of the CT images were stored in digital imaging
different for the right (8.2mm) and left sides (8.1mm). and communications in medicine (DICOM) file format, and
Considering these dimensional measurements, addi- a set of stacked two-dimensional cross-sectional images was
tional dental compound impression material can be added imported (Figure 1(a)). A segmentation was applied to each
across the hamular notches and palate during border mold- 3D model to identify and separate the palatal mucosa from
ing. Post damming is established as a part of a total peripheral the surrounding tissues. Predefined settings of the Hounsfield
seal, not a separate entity, by pressing the posterior border range were established for the density of the biological tissue
with an additional compound. This procedure is known as a in which a lower threshold allows segmentation of soft tissue,
selective pressure impression technique [8–10]. A wide PPS whereas a higher threshold allows segmentation of bone. A
area is optimal because it allows placement of a substantial thresholding allows soft tissue to easily be separated from
seal. The depth of the PPS area is determined by the degree of bone. After classifying the pixels, a segmentation was per-
vertical movement of the soft palate, and the degree of vertical formed to reconstruct the palate mucosa and teeth 3D model
movement of the soft palate is influenced by the thickness of by removing unnecessary images from a mask (Figure 1(b)).
soft palate. The thicker the soft palate, the more vertical the
movement of the soft palate [11]. However, the post damming
2.4. Measurement of the Posterior Palatal Mucosa Thickness.
is performed empirically by clinicians. To date, few studies
The reconstructed palate 3D models were calibrated using
have been reported on the scientific measurements of the
3-matic software (ver. 11.0; Materialise, Leuven, Belgium).
thickness and dimensions of the PPS area.
The intersection point of the vertical line drawn at the
Data about the exact dimensions and thickness of the
incisive papilla on the line connecting both hamular notches
PPS area allows the post damming to be performed with
is defined as the center point. Using the above four reference
more specific guidelines. The purpose of this study was to
points, three planes perpendicular to each other are formed
assess and measure the dimensions and thickness of the
passing through the center point and referred to as reference
palatal mucosa of the oral cavity in a systematic manner using
planes of the coronal plane, sagittal plane, and horizontal
reconstructed three-dimensional (3D) model to objectively
plane. In coronal plane, all models were divided into 2 mm
determine the dimensions of the PPS area.
intervals forward from the hamular notch line parallel to the
coronal plane, and 7 sections were measured (Figure 2(a)). In
2. Materials and Methods sagittal plane, 3 mm intervals to both sides from the mid-plate
parallel to the sagittal plane and 15 sections were measured
The present study was approved by the Institutional Review (Figure 2(b)). The thickness was measured at 93 crossing
Board (KHD IRB 1712-2). points of each divided plane (Figure 2(c)).

2.1. Subjects. Retrospective analysis was performed using

computed tomography (CT) images taken at the Dental 2.5. Dimensions of the Posterior Palatal Seal Area. The PPS
Hospital from July 2012 to October 2017. A total of 54 area was determined based on the wall thickness analysis
patients underwent CT with open mouth, and 34 patients of 3-matic software. Two points were marked at the most
were excluded due to the following conditions: (1) 8 cases forefront points on both sides of the anterior border of
with abnormal maxillary deformations, (2) 24 cases that the red region, and one point was marked at the rearmost
experienced difficulties in separating the palatal mucosa from point of the anterior border of the red region. The red color
the surrounding soft tissue, and (3) 2 cases with severe metal indicated greater thickness compared with other areas. The
artifacts due to the dental prosthesis. Consequently, the study PPS area dimensions were measured between these 3 points,
was performed on CT images of 20 subjects (11 males and 9 in addition to the coronal and sagittal plane (Figure 3).
females; 21 to 80 years of age).
2.6. Statistical Analysis. Statistical analysis was performed
2.2. CT Device. The high-resolution 128-slice multidetector using IBM SPSS software (ver. 23.0; IBM SPSS Inc., Chicago,
computed tomography (MDCT) (Ingenuity Core 128; Philips IL, USA) for WIN. All data were subjected to normality
Medical Systems, Best, The Netherlands) and 64-slice MDCT and homogeneity of variance on a Shapiro-Wilk test for
(Aquilion Prime Model TSX-303A; Toshiba Medical Systems each group. The t-test was used to examine the significant
Corp., Tokyo, Japan) scanners were employed with an axial difference between the right and left dimensions of the PPS
slice thickness of 0.5-1.0 mm. Anatomic modeling requires area. The significance level was set at 5%.
selection of a defined Hounsfield unit (HU) from CT data that
establishes a threshold for accurate modeling of the required
tissue type.
3. Results
3.1. Thickness of the Posterior Palatal Mucosa. The mean
2.3. 3D Model Reconstruction from CT Image. The CT images thickness values were ranged from 1.71 mm to 6.59 mm and
of the patients were analyzed and Mimics software (ver. 19.0; varied according to the PPS region. The thickness value was
Materialise, Leuven, Belgium) was used to generate com- gradually thickened toward the posterior border of the PPS
puterized composite palate models of the patients, including area and the anterior to posterior variation of the thickness
the soft tissue and dentition. To reconstruct data in Mimics decreased gradually from the center of the palate toward the
BioMed Research International 3

(a) (b)

Figure 1: Two-dimensional cross-sectional CT images were stacked, reconstructed 3D model, and segmented palatal mucosa and teeth model.
(a) Reconstructed 3D model. (b) Palatal mucosa and teeth model.

IP IP

HN HN HN HN

(a) (b)

12
10
8
6
4
2
HN

-18 -12 -6 0 6 12 18
-21 -15 -9 -3 3 9 15 21

(c)

Figure 2: Model was divided and thickness of mucosa was measured at 93 points. (a) Seven sections parallel to coronal plane at 2mm intervals
from HN line. (b) 15 sections parallel to sagittal plane at 3mm intervals from mid-palatal line to both sides. (c) 93 crossing points of each
divided plane. IP, incisive papilla; HN, hamular notch.

lateral side. The thickness value was the smallest in the mid- mean dimension from the mid-palatal plane to the right
palatal area. The thickness value was increased in the lateral most forward point was 6.85 mm, and the left was 7.36 mm
direction and the largest values of the right and left sides were and there was no significant difference between both sides
9 mm from the center of the palate of the most posterior (p>0.05) (Table 2).
line of the PPS area; after that, it decreased again (Table 1,
Figure 4). 4. Discussion
3.2. Dimensions of the Posterior Palatal Seal Area. The mean Retention is essential for the successful treatment of the
dimension between the rearmost of anterior border and the maxillary complete denture. The retention of the denture has
hamular notch plane in the PPS area was 2.19 mm and the been defined as the resistance to vertical movement away
mean dimension between the forefront of anterior border from the tissues [12] and as a quality that is inherent in the
and the hamular notch plane was 5.19 mm in the right prosthesis to resist dislodgement forces along the path of
side and 5.16 mm in the left side. There was no significant insertion [13]. It is important to discuss and identify factors
difference between the right and left sides (p>0.05). The associated with the retention of the complete denture, the
 4

Table 1: Mean thickness value (±SD) of posterior palatal mucosa (mm).

R7 R6 R5 R4 R3 R2 R1 O L1 L2 L3 L4 L5 L6 L7
A6 3.71 (0.80) 4.76 (0.78) 4.40 (1.22) 2.89 (1.07) 1.87 (0.79) 1.71 (0.59) 2.09 (0.79) 3.16 (1.01) 4.19 (1.23) 4.49 (0.64) 3.66 (0.88)
A5 3.90 (0.99) 5.01 (0.93) 4.54 (1.14) 3.12 (0.88) 2.05 (0.83) 1.75 (0.67) 2.35 (0.82) 3.33 (1.06) 4.37 (1.26) 4.88 (0.60) 3.82 (1.03)
A4 3.00 (1.04) 3.97 (1.22) 5.31 (1.02) 4.58 (0.98) 3.35 (0.93) 2.27 (0.91) 1.91 (0.73) 2.52 (0.99) 3.55 (1.19) 4.68 (1.29) 5.37 (0.76) 3.98 (1.08) 2.56 (1.02)
A3 2.85 (1.40) 4.23 (1.37) 5.55 (1.01) 4.89 (1.03) 3.77 (0.99) 2.60 (1.14) 2.10 (0.89) 2.80 (1.09) 4.01 (1.06) 5.10 (0.98) 5.54 (0.76) 4.06 (1.28) 2.42 (1.06)
A2 3.47 (1.56) 2.95 (1.38) 4.42 (1.40) 5.81 (0.86) 5.20 (1.04) 4.42 (1.10) 3.11 (1.17) 2.51 (0.95) 3.34 (1.12) 4.50 (1.08) 5.41 (1.06) 5.64 (0.68) 4.18 (1.37) 2.82 (1.18) 3.07 (1.20)
A1 3.52 (1.54) 3.31 (1.38) 4.51 (1.10) 6.25 (0.97) 5.88 (1.15) 5.26 (1.29) 3.91 (1.32) 3.36 (1.16) 4.19 (1.30) 5.47 (1.29) 5.92 (1.16) 5.85 (0.81) 4.60 (1.40) 3.37 (1.17) 3.48 (1.18)
HN 3.78 (1.45) 3.71 (1.26) 4.96 (1.20) 6.30 (1.20) 6.59 (1.34) 5.87 (1.63) 4.89 (1.62) 4.32 (1.53) 5.07 (1.68) 6.15 (1.56) 6.50 (1.14) 5.91 (1.37) 4.84 (1.38) 3.96 (1.09) 3.76 (1.35)
HN, hamular notch line; O, mid-palatal line; A1, 2 mm anterior to HN; A2, 4 mm anterior to HN; A3, 6 mm anterior to HN; A4, 8 mm anterior to HN; A5, 10 mm anterior to HN; A6, 12 mm anterior to HN; R1, 3
mm right to midline; R2, 6 mm right to midline; R3, 9 mm right to midline; R4, 12 mm right to midline; R5, 15 mm right to midline; R6, 18 mm right to midline; R7, 21 mm right to midline; L1, 3 mm left to midline;
L2, 6 mm left to midline; L3, 9 mm left to midline; L4, 12 mm left to midline; L5, 15 mm left to midline; L6, 18 mm left to midline; L7, 21 mm left to midline.
BioMed Research International
BioMed Research International 5

7.0000
5.9341 RW LW
4.8683
3.8024
2.7365
1.6707 P1 P2
0.6048
P0

RD LD
12
10
8
6
4
2
HN

-18 -12 -6
-21 -15 -9
0
3
6 12 18
9 15 21
OD
-3

(a) (b)

Figure 3: Thickness of mucosa was measured and displayed in color, and the PPS area was determined. (a) Color map of thickness and the
PPS area border line. (b) Diagram of vertical plane of the PPS area. P0, rearmost point of anterior border; P1, foremost point of anterior border
of right side; P2, foremost point of anterior border of left side; RW, dimension between P1 and mid-palatal line; LW, dimension between P2
and mid-palatal line; OD, dimension between P0 and hamular notch line; RD, dimension between P1 and hamular notch line; LD, dimension
between P2 and hamular notch line.

Mean thickness (mm)

Post.
7
6
5 8
4 Post.
3 6
2
1 4
0 Ant.
R7 R6 R5 R4 R3 R2 R1 O L1 L2 L3 L4 L5 L6 L7 2

A6 0 Ant.
A2 R7 R6 R5
A5 A1 R4 R3 R2
R1 O L1
A4 HN L2 L3 L4
L5 L6
A3 L7
(a) (b)

Figure 4: Mean thickness value of mucosa at measured points. (a) 3D column chart. (b) 3D surface chart. O, mid-palatal plane; R1-17, and
L1-L7, sectioned plane; HN, hamular notch line; Ant., anterior direction; Post, posterior direction.

importance of the PPS, its location, design, placement, and The dimensions and thickness were measured in this
influence on processing. study to provide a more robust assessment of the PPS
The PPS area is the portion of the intaglio surface applications. Many studies have demonstrated the possibility
of a maxillary removable complete denture located at the of using images to measure the thickness of the palatal
posterior border, which places pressure, within physiologic masticatory mucosa with conventional CT, cone beam com-
limits, on the PPS area of the soft palate; this seal ensures puted tomography (CBCT), and ultrasonic devices [16–18].
intimate contact of the denture base to the soft palate and Compared to conventional CT, CBCT presents advantages
improves the retention of the denture [13]. The importance such as lower radiation, greater comfort for the patient, and
and function of the PPS cannot be overemphasized in lower costs. However, due to the low contrast resolution in
successful maxillary complete dentures. The contact was CBCT scans, data from CBCT studies are less reliable for soft
maintained by sealing between the denture and soft tissue tissue measurement [19]. Histograms of MDCT data reveal
during functional movements of the stomatognathic system, distinct peaks that generally correspond to hard and soft
which then decreases the gag reflex. The food accumulation tissue types, whereas CBCT plots revealed a more diffuse
was decreased by sealing with adequate tissue compressibility appearance. Segmentation of CT data is a necessary step for
and also patient discomfort was decreased when the tongue creating anatomical models. Pixel thresholding, often based
contact on the posterior part of the denture. The PPS not only on peaks seen in pixel histograms, is a typical method for
increases retention and stability by making a partial vacuum, segmentation of bone in CT scans. The lack of distinct peaks
but also compensates for the volumetric shrinkage that in CBCT histograms compared to MDCT data indicates less
occurred during polymethyl methacrylate polymerization. contrast resolution in CBCT scans [19]. Data from MDCT
Finally, the strength of the denture base was increased by the studies is acceptable as a threshold for anatomic model
PPS [5, 14, 15]. output. Ultrasonic devices were reported to have highly
6 BioMed Research International

Table 2: Mean dimension value (±SD) of right and left PPS area (mm).

OD RD LD RW LW
Mean (±SD) 2.17 (1.17) 5.19 (1.69)a 5.16 (1.70)a 6.85 (1.68)b 7.36 (1.81)b
Same superscript letters indicate statistically similar groups (p>0.05).
OD, dimension between P0 and hamular notch line; RD, dimension between P1 and hamular notch line; LD, dimension between P2 and hamular notch line;
RW, dimension between P1 and mid-palatal line; LW, dimension between P2 and mid-palatal line.

accurate measurements, showing a correlation coefficient Intraoral scanning of the edentulous ridges has also been
of 0.921. However, the reliability of the measurement was studied [25, 26]. However, there are limitations t fabricating
relatively low (measurement error: 0.54) [20]. Although the retentive and supportive complete dentures with only the
ultrasonic device was noninvasive and easily applicable, this intraoral scanning of the edentulous area. Intraoral scan-
method is technique sensitive, has low reproducibility, and ning can be performed only via a nonpressure impression
has limitations in sites with a palatal vault depth [21]. This technique. Unlike fixed prosthesis, the selective pressure
study used conventional CT data, which provide measure- technique should be applied to create a complete denture.
ments of the posterior palatal mucosa with no limitation due Based on this study, it is possible to selectively pressure the
to anatomical structure and have high accuracy, better quality PPS area by superimposing reconstructed 3D model and
of reconstructed 3D images, and ease of standardization. intraoral scanning data of the maxillary edentulous arches
In previous studies, the palatal mucosa thickness was based on radiopaque resin marker [25]. Therefore, by accu-
measured comparing to the tooth. However, for the mucosal rate analysis of the dimension and thickness of the PPS area,
thickness measurement research of edentulous patients, it clinicians can perform nonpressure intraoral scanning and
is necessary to measure using anatomical structures other revise the scan data to selectively press the palatal mucosa.
than teeth as indicators. In this study, the thickness was Also, incorporating into digital workflows and combining
measured according to the distance from the midline and the it with other digital devices like intraoral scanner, more
hamular notch line, and the mean thickness of the palatal accurate and clinically effective digital complete denture can
mucosa varied according to region of the PPS area. The be manufactured.
value gradually thickened toward the posterior border of the
PPS area. The anterior to posterior variation in thickness
decreased with distance from the mid-palatal line. The 5. Conclusions
boundary of the hard palate at the junction of the hard and
The thickness of the palatal mucosa was thicker toward the
soft palates is typically butterfly-shaped. The point at which
posterior area and increased in the lateral direction and
the soft palate meets the hard palate is more forefront at the
decreased again. The anterior border of the PPS area was
lateral side of the palate rather than at the palatal midline
a butterfly shape and there was no significant difference
[22]. This anatomical feature provides an explanation for the
between the right and left side dimensions of the PPS area.
anteroposterior mucosal thickness variation of the posterior
A new noninvasive method to consistently obtain images
palate relatively large increasing at the center of the palate
and measurements of the posterior palatal mucosa is
compared to the lateral sides.
described. This reliable and reproducible method could be
The average anterior to posterior dimension of the PPS
beneficial for analyzing soft tissue and can be used to plan and
area was from 2 mm to 5 mm. Narvekar and Appelbaum [19]
fabricate the maxillary complete denture in digital workflow.
reported that, in an ultrasonographic study of 15 participants,
the average range for the anterior to posterior dimension of
the PPS area was estimated to be between 4 mm and 6 mm. Data Availability
According to Hardy and Kapur [6], the PPS area can usually
be extended forward about 4 mm from the posterior border of The CT images and reconstructed and calibrated 3D model
the denture, and Silverman [7] found that the greatest mean data used to support the findings of this study are restricted
of the anteroposterior width of the PPS area is 8 mm (with by the Institutional Review Board (KHD IRB 1712-2) in order
5-12 mm range). The differences in the dimension of the PPS to protect patient privacy.
area reported in various studies may be attributed to several
factors. First, different anatomical references and methods
were used to identify the anterior and posterior borders of Conflicts of Interest
the PPS area. Additionally, in studies that used vibrating lines
The authors declare that there are no conflicts of interest
to determine the PPS area, consistently marking the vibrating
regarding the publication of this paper.
line would be difficult.
Digital technology has been adopted in clinical dentistry,
and the digital impression technique has more recently Acknowledgments
been applied for fabricating various types of prostheses [23,
24]. Fixed prostheses and implant prostheses can now be This work was supported by a grant from Kyung Hee
created without conventional impression materials and casts. University in 2015 [KHU-20150842].
BioMed Research International 7

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